On October 1, 2017, CMS expanded its pilot Targeted Probe and Educate (“TPE”) program to include all MACs. CMS’s stated purpose for the expansion is “to reduce appeals, decrease provider burden, and improve the medical review/education process.” CMS has described the program as “designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.” This is a 3-round program conducted by the provider’s local MAC. It offers one-on-one education and is intended to reduce payment error rates for the provider. Hopefully, the provider is also able to use the program to avoid an overpayment demand or payment suspension.

How the TPE Program works:

The MACs will chose providers through data analytics who have high claim error rates or unusual billing practices.

Once a provider is chosen, the MAC must send a notice to the provider informing them that the TPE review has been initiated and providing details of the provider’s obligations under the program.

ROUND 1: Shortly thereafter, the MAC will send a request for medical records and other documentation to support 20-40 claims.

The provider has 45 days to collect all the documentation and return it to the MAC.

The MAC then has 30 days to review the claims and supporting materials. The MAC sends the provider a letter detailing the results of the claim review and claim errors. The MAC also offers the provider the opportunity for a one-to-one educational call.

If the provider is deemed compliant, it will not be reviewed again for least 1 year on the same topic.

The acceptable claim error rate will be dependent upon the service or item under review.

ROUND 2: If the MAC deems the provider was not compliant in round 1, then a few months later, the MAC will send another request for documentation for an additional 20-40 claims and the same process is followed.

ROUND 3: If the provider is not compliant again the same process occurs for a third and final time.

Providers only have 3 rounds to become compliant. If there is a failure to improve after 3 rounds, the provider will be referred to CMS for next steps, which can include 100% pre-payment review, extrapolation, referral to a RAC or UPIC, or other consequences.

It is important for providers to note that the TPE process does NOT toll the appeal process under Medicare and those deadlines are still in effect.

We anticipate our clients will soon begin to see these TPE notification letters. We encourage you to engage us as soon as you receive the first letter so that we can assist you in creating a compliant response during the first round, if possible, to avoid unnecessary burden to your daily business.

Mr. Cooper provides legal representation to a broad range of hospitals, other healthcare facilities and physician groups across the United States. He has been listed in The Best Lawyers in America for health law for twenty-three consecutive years and selected for inclusion in Ohio Super Lawyers (2005-2015).